The Journal of Thoracic and Cardiovascular Surgery

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Accepted Manuscript The mid-life crisis of the meta-analysis Joanna Chikwe, MD, FRCS, Aaron Weiss, MD PII: S0022-5223(18)33158-1 DOI: https://doi.org/10.1016/j.jtcvs.2018.11.

1 Accepted Manuscript The mid-life crisis of the meta-analysis Joanna Chikwe, MD, FRCS, Aaron Weiss, MD PII: S (18) DOI: Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 13 November 2018 Accepted Date: 14 November 2018 Please cite this article as: Chikwe J, Weiss A, The mid-life crisis of the meta-analysis, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 The mid-life crisis of the meta-analysis First author: Chikwe Authors names, academic degrees and affiliations: Joanna Chikwe MD, FRCS 1,2, Aaron Weiss MD 1 1) Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, USA 2) Department of Surgery, The State University of New York, Stony Brook, NY, USA Corresponding author: Joanna Chikwe Correspondence: Department of Cardiovascular Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, New York, NY USA Telephone: Cellular: Fax: Joanna.Chikwe@mountsinai.org Total word count: 488/500 Disclosure: Jo Chikwe speaker honoraria for Edwards Lifesciences Central Message: In patients aged years either a bioprosthetic or mechanical valve replacement remains a reasonable choice. Word count: 16 words / 122 characters (max 25 words / 135 characters with spaces) Central Picture Legend 15-year survival after bioprosthetic vs mechanical aortic valve replacement Word count: 9 words / 75 characters (max 15 words / 90 characters with spaces)

3 Page 1 of 4 The mid-life crisis of the meta-analysis The meta-analysis is forty years old, and having a mid-life crisis. 1 Conceived in the 1970 s, the metaanalysis synthesizes studies to provide best evidence through systematic review, rigorous statistics and formal protocols promoting reproducibility and reducing bias. But success has not come without problems. A recent editorial in Nature observes: One undesirable consequence of the growing recognition and high impact of meta-analysis is an increase in less-than-rigorous applications of these methods Meta-analyses and systematic reviews can highlight areas in which evidence is deficient, but they cannot overcome these deficiencies they are systematic and scientific techniques, not magical ones. 1 Which brings us to the meta-analysis in this issue of the Journal, in which Diaz et al compare bioprosthetic with mechanical aortic valves in patients aged years. The authors include one randomized and four observational studies encompassing 4686 patients, reporting a small survival advantage with mechanical valves. 2 Before recommending a mechanical aortic valve on the basis of this data, surgeons and cardiologists should consider these three points: 1) Current best evidence indicates no significant difference in long-term survival after bioprosthetic versus mechanical aortic valve replacement in patients aged years. 2) Transcatheter valve-in-valve has lowered the risks associated with reintervention for bioprosthetic structural valve degeneration. 3) Stroke and bleeding carry substantial mortality and morbidity, and remain commoner long-term after mechanical than biological valve replacement. The single randomized trial performed in this age-group showed no significant survival difference 15 years after bioprosthetic versus mechanical aortic valve replacement, findings confirmed by two large observational analyses in the NEJM and JAMA (Figure). 3-5 These studies successfully address the inherent confounding bias arising when specific patient characteristics predict both the outcome and the choice of intervention in this case shorter estimated life-expectancy and noncompliance both of which predict reduced survival and a bioprosthesis. Randomization is the most effective way of distributing these confounders evenly between comparison arms: consequently, a well-designed meta-analysis of randomized trials is best evidence, and synthesizing data from multiple randomized studies is a particularly valuable approach when the available trials are underpowered and inconclusive. 1

4 Page 2 of 4 However, the study by Diaz et al is a meta-analysis dominated by non-randomized studies, mostly limited by confounding bias favoring mechanical valves. Additionally, the authors chose not to include relevant, well-designed studies such as the NEJM analysis. Consequently, their meta-analysis results are unreliable. Perhaps more importantly, this data no longer reflects contemporary practice, primarily because of the changing balance of risks associated with valve-related reoperation, bleeding and embolic stroke. Transcatheter valve-in-valve has reduced mortality of reintervention for bioprosthetic degeneration for many patients, whereas the considerable mortality and morbidity associated with stroke and major bleeding (both more common after mechanical than bioprosthetic valve replacement), remains substantially unchanged. 6 In summary, this meta-analysis provides no reason to deviate from clinical practice based on individual patient preference and risk factors, consensus guidelines and best evidence. In patients aged years of age, either a bioprosthetic or mechanical valve replacement remains a reasonable choice. Word count: 488 (Max 500) References 1) Gurevitch J, Koricheva J, Nakagawa S, Stewart G. Meta-analysis and the science of research synthesis. Nature. 2018; 555: ) Diaz R, Hernandez-Vaquero D, Alvarez-Cabo R, Avanzas P, Silva J, Moris C, et al. Mechanical versus biological aortic prosthesis in the long-term. Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2018 (In Press) 3) Stassano P, Di Tommaso L, Monaco M, Lorio F, Pepino P, Spampinato N, Voas C. et al Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009; 54: ) Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick WL, Fischbein MP, Woo YJ. N Engl J Med 2017; 377: ) Chiang YP, Chikwe J, Moskowitz AJ, Itagaki S, Adams DH, Egorova NN. Survival and longterm outcomes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA 2014; 312:

5 Page 3 of 4 6) Tuzcu EM, Kapadia SR, Vemlapalli S, Carroll JD, Holmes DR Jr., Mack MJ, et al. Transcatheter aortic valve replacement of failed surgically implanted bioprostheses: The STS/ACC Registry. J Am Coll Cardiol 2018; 72:

6 Page 4 of 4 Figure Legend 15-year survival in 2002 propensity matched patients aged years after bioprosthetic vs mechanical aortic valve replacement. 4 4

Accepted Manuscript. Sixteen Years Later and the Debate for TAVR or SAVR Remains Controversial. Saina Attaran, MD, Vinod H.

Accepted Manuscript. Sixteen Years Later and the Debate for TAVR or SAVR Remains Controversial. Saina Attaran, MD, Vinod H. Accepted Manuscript Sixteen Years Later and the Debate for TAVR or SAVR Remains Controversial Saina Attaran, MD, Vinod H. Thourani, MD PII: S0022-5223(18)30624-X DOI: 10.1016/j.jtcvs.2018.02.080 Reference: